Provider Demographics
NPI:1689824682
Name:MCNULTY, ANNMARIE (CPNP)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4507
Mailing Address - Country:US
Mailing Address - Phone:602-252-5121
Mailing Address - Fax:602-242-6945
Practice Address - Street 1:4434 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4507
Practice Address - Country:US
Practice Address - Phone:602-242-5121
Practice Address - Fax:602-242-6945
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ382746Medicaid